Trusted contraception information sources for individuals with opioid use disorder

Abstract Objective (Study Question) To identify trusted sources of contraception information among pregnancy‐capable individuals with opioid use disorder (OUD). Data Sources/Study Setting We conducted interviews between October 2018 and January 2019 at Boston Medical Center, a university‐based tertiary care center. Study Design Data were drawn from semi‐structured qualitative interviews with a convenience sample of 20 pregnant or recently pregnant individuals with OUD. We used the Ottawa Decision Support Framework, a health decision making conceptual model, to structure our interviews. We analyzed the data using inductive and deductive coding. Data Collection/ Extraction Methods Not applicable. Principal Findings Pregnancy‐capable individuals who use opioids value friends who are not actively using opioids, including peers in recovery homes, as trusted sources of contraception information. They also value internet resources, including websites recommended by clinicians and social media posts, and established clinical providers as reliable sources of contraception information in ways that emulate individuals with other chronic medical conditions. Conclusion These sources of contraception information may explain some trends in contraceptive use among individuals with OUD, inform nonstigmatizing contraceptive counseling, and serve as a foundation for improved decision support.


What this study adds
• Persons with opioid use disorder value peers who were not actively using opioids as trusted sources of contraception information • Persons with opioid use disorder value contraceptive counseling in which clinicians center their lived contraception experiences and personal goals 1 | INTRODUCTION People with chronic conditions are at increased risk of having unintended pregnancies. Yet these individuals often require multidisciplinary and proactive pregnancy planning for optimal maternal and fetal health. 1,2 While 45% of pregnancies in the general population are considered unwanted, or unintended, one study found that participants with opioid use disorder (OUD) were nearly twice as likely to report this outcome. 3,4 Contraceptive use patterns differ between people with chronic conditions, including diabetes, cardiovascular disease, asthma, HIV, and OUD and those without. 1,5,6 Similar to persons with HIV, individuals with OUD make their contraceptive decisions in the context of a highly stigmatized chronic condition, societal views that they should not become pregnant, and a history of coercive contraceptive practices. 5,7,8 Given this systems-level devaluation of their reproductive autonomy compounded by the high-risk nature of pregnancy for many people with chronic conditions, individuals with OUD may not feel comfortable explicitly stating their pregnancy intentions to a clinician. 9 Contraceptive decision making and use for persons with OUD also occurs in the context of perceived and actual decreased fertility, sexual partner power dynamics, and the intersection of common contraceptive side effects and active opioid use. [10][11][12] Standard assessments of contraceptive use among women with substance use disorder (SUD) are limited. Yet one systematic review reported that 56% of women with SUD utilized contraception, compared to 81% individuals without SUD. 13 Patients make contraceptive decisions informed by the recommendation of medical professionals, but also with the input of partners, friends, family, and social media networks. [14][15][16][17][18] Yet little is known about the contraceptive information sources valued by individuals with OUD. As such, we sought to understand patient perspectives on trusted sources of contraception information for pregnancy-capable individuals with OUD.

| METHODS
As part of our broader exploration of contraceptive decision making among pregnancy capable individuals with OUD, we conducted semistructured qualitative interviews between October 2018 and January 2019 at Boston Medical Center, a university-based care center.
We recruited our sample from Project RESPECT (Recovery, Empowerment, Social Services, Prenatal care, Education, Community and Treatment), a specialized outpatient obstetric clinic for patients with substance use disorder (SUD), the SOFAR (Supporting Our Families through Addiction and Recovery) program, an outpatient clinic for parents in SUD recovery and their children, and an inpatient maternal fetal medicine service, where patients are admitted for inpatient medication for OUD titration. Participants were recruited via provider referral, self-referral in response to flyers, and referral by prior participants. Eligibility criteria were (1) currently pregnant or pregnant within one year regardless of outcome, (2) self-identified OUD, (3) 18 years old or older, and able to consent, and (4) English speaking. We continued recruitment until we reached thematic saturation. We provided a $50 gift card for participation.
We obtained written informed consent prior to each interview.
Interviewers (LS and YWL) both identified as female and were an OB-GYN resident and OB-GYN medical student with prior qualitative interviewing experience. They were not directly involved in the participants' medical care. They conducted in person interviews in the clinical environment. Interviews were audio recorded and professionally transcribed. Interviewers took field notes after the conclusion of each interview.
We structured our interview guide around the Ottawa Decision Support Framework, an internationally recognized conceptual model describing health decision making. 19 Interviews began with the openended statement: "Tell me about the contraceptive methods you've used in the past" followed by questions related to the Ottawa Decision Support Framework decisional needs. We specifically explored trusted information sources in our interview guide. This topic was initiated with the anchor question: "Tell me about where you get your birth control information". This question was followed by probing questions, including: "Do you feel that one of these sources has been most helpful to you?" and "Which one of these do you think is the best source of information?". We administered a demographic survey after the interview which we entered into REDCap. 20 LS and EWP independently analyzed five transcripts using inductive and deductive coding to develop a codebook. Each subsequent transcript was coded by LS and either EWP or YWL. They met regularly to ensure coding consistency, resolve discrepancies through consensus, and iteratively revise the codebook. We used NVivo 11 software to manage our data and facilitate coding. The Boston University Institutional Review Board approved this study.

| RESULTS
We screened 131 individuals and approached 58 for study participation. Twenty-two individuals ultimately completed interviews.
Patients most often declined participation due to time constraints or withdrawal symptoms. Two interviews were not included in the final analysis because the identified their primary substance use to be cocaine or alcohol rather than opioids. (Table 1). Four primary contraception information sources valued by individuals with OUD emerged.
3.1 | Trusted information source 1: Friends who have never used opioids and those stable in recovery Participants commonly cited friends as sources of contraception information. They noted that friends who had never used opioids, as well as those who were stable in their recovery, modeled admirable preventative health care behaviors. This resulted in more value being placed on the health information they provided: "My girlfriends that like don't think it's okay to shoot heroin with your kid in the next room… You know? I consider them my normal friends. They're all on birth con-trol… [and take it] at a certain time every day… and it's like clockwork. I listen to them" (Participant 7). They also described that friends who regularly engaged with social media were less likely to be actively  hygiene related to bleeding patterns in the setting of housing instability, and interactions with mood stabilizing medications. 9

| Trusted information source 4: Personal experience and research
Participants strongly desired that their clinicians understood the

| DISCUSSION
Understanding the contraception information sources valued by persons with OUD provides a foundation for improved patient-centered and nonstigmatizing counseling, as well as multiple points for evidence-based interventions.
Clinicians use a variety of communication strategies when engaging in contraception counseling. Directive counseling can lead to experiences with clinician-based reproductive coercion to use highly effective contraceptive methods, which contributes to health care system distrust. 22 Data supports grounding contraception counseling for individuals with OUD in an open and supportive narrative about reproductive goals, which align with their pursuit of sustained recovery. 9,22,23 Structured counseling models such as the PATH framework and PHI CARE may support the elicitation of patients' family planning values. 24,25 Consistent with this approach, participants describe a preferred contraception counseling dynamic, which centers on their lived contraceptive experiences, as well as their contraceptive values and goals.
People with chronic conditions often seek condition-specific contraceptive counseling. Thus, after acknowledging the expertise of the patient, the role of the clinician is to contribute information on each method contextualized by data specific to OUD. While participants feel clinicians who provide contraception counseling are generally familiar with the mechanism of action and common sideeffects of each method, they often feel that they are unable to ground their discussion in the unique needs and preferences of persons with OUD.
Our data highlight that regardless of specialty, the development of a trusting contraception counseling relationship is predicated on the clinician providing contraceptive information in the context of this chronic disease, as well as demonstrating the knowledge of pertinent reproductive health topics specific to OUD. To our knowledge, there is only one contraception information resource developed by professional societies specific to individuals with OUD. 26 A focus on developing both clinician-facing and patient-facing evidence-based contraception resources would allow for clinician engagement in a more informed dialogue with individuals with OUD and allow them to empower patients to gather evidence-based contraception information in the context of their chronic disease.
One sequela of this lack of contraception information specific to individuals with OUD is that information sources outside the health care system are highly valued by this population. Individuals with chronic conditions are commonly excluded from contraception clinical trials, yet they are often actively engaged in disease-specific internet threads and forums. 27 Social media is used to provide social, emotional, and experiential support, with one study noting Facebook and blogs are more likely to improve, rather than harm care for people with chronic conditions. 28 Consistent with prior studies of individuals with chronic conditions, no participants promoted the involvement of health care professionals in their social media forums. 29 To our knowledge, there are no social media forums that discuss contraceptive evidence and experiences among individuals with OUD moderated by trained peer moderators. Training individuals already involved in these forums to be peer moderators would provide a patient-led and accessible contraception intervention for individuals with OUD.
Our study also highlights the recovery home environment as a valued source of contraception information. Unlike other chronic con-  33 We are thus unable to comment on the intersectional experiences of OUD and contraception care experienced by patients of different races and ethnicities. We also focused our sample on patients who were or had recently been pregnant but did not ask about pregnancy intention. It would be valuable to understand more about how contraceptive information received had or had not supported patients' fertility goals. Last, we collected these data prior to the onset of the COVID-19 pandemic. Thus, our study does not address the health system changes, including decreased in-person contact with the health care system, increased use of telemedicine with insurance reimbursement, and social distancing in recovery homes. 30 In conclusion, an understanding of the contraception information sources valued by individuals with OUD may have significant implications for building therapeutic relationships and for the dissemination of accessible, evidence-based, and trusted contraception information among individuals with OUD.

ACKNOWLEDGMENTS
We are grateful for the contributions and wonderful care provided by Kelley Saia, MD, Eileen Costello, MD, and the dedicated teams at Project RESPECT and the SOFAR program.